Plastics

● Submandibular
● Retromandibular / transparotid
● Preauricular
● Transconjunctival / lateral canthotomy / transcaruncular
● Subciliary / Subtarsal
● Coronal
● Upper bleph
● Rhino/septoplasty
● Gilles
● Lefort
● BSSO
● Modified condylotomy
● Anterior hip
● Posterior hip
● Tibia
● Rib
● Fibula
● Tracheotomy

Submandibular:
Incision: 2cm below inferior border of the mandible
Layers: Skin, subcutaneous tissue, platysma, superficial layer of deep cervical fascia, pterygomasseteric sling, periosteum, mandible
Important structures: facial artery, facial vein, marginal mandibular branch of facial nerve, submandibular gland.
- Marginal mandibular nerve passes 1.2cm below inferior border.
Complications: marginal mandibular branch facial nerve damage, hematoma

Retromandibular / Transparotid:
- Hinds approach
Incision: 0.5 cm below earlobe, continues inferiorly 3 - 3.5cm just behind posterior border of mandible.
Layers: skin, subcutaneous tissue, scant platysma, SMAS/parotid capsule, pterygomasseteric sling, periosteum, mandible
- Sigmoid notch retractor can be useful for retraction Important structures: parotid gland, marginal mandibular branch of facial nerve, retromandibular vein
Complications: salivary fistula (treatment with pressure dressing, scopolamine patch, pro banthine).

Coronal Incision:
Layers: skin, subcutaneous tissue, galea, subgaleal (loose areolar tissue), pericranium Laterally the musculoaponeurotic layer becomes temporoparietal fascia
Important structures: Superficial temporal artery (just superficial to temporoparietal fascia), supraorbital neurovascular bundle, temporal branch of facial nerve (just deep to or within temporoparietal fascia).
Complications: nerve injury, hematoma, alopecia
Upper eyelid / bleph Incision: 10mm superior to upper lid margin and 6mm superior to lateral canthus (can extend as far laterally as needed for surgical access)
Layers: skin, orbicularis oculi, periosteum (incised 2-3mm posterior to orbital rim)
Important structures: Levator palpebrae superioris, Muller's muscle (superior tarsal muscle), lacrimal gland, orbital septum
Complications: ptosis, epiphora, ocular injury

Preauricular:
Incision: skin fold along entire aspect of the ear within 8mm of EAC. incise to the depth of the superficial layer of the temporalis fascia.
Layers: Temporal region (skin, subcutaneous, temporoparietal fascia, superficial temporalis fascia, temporal fat pad, deep temporalis fascia).
Dissection to the Joint Capsule: along the anterior portion of the EAC to avoid superficial temporal vessels and auriculotemporal nerve, Above the arch bluntly dissect 1.5 to 2cm anteriorly to the level of the superficial temporalis fascia, below the arch bluntly dissect parallel to and along the EAC cartilage. Incise the superficial layer of the temporalis fascia just anterior to the tragus at the zygoma in anterior superior direction. Incise periosteum and reflect to reveal TMJ capsule.
Important structures: STA (superficial temporal artery (within the TP fascia), auriculotemporal nerve, temporal branch of facial nerve cross 8 to 35mm average 20mm from the anterior most portion of the EAC where the upper trunk cross the zygomatic arch.
Complications: facial nerve injury, perforation into EAC
The TMJ is a ginglymoarthrodial joint (rotation and translation)

Transconjunctival: (aka inferior fornix approach)
- Preseptal and retroseptal (retroseptal more direct and easier to perform) - Lateral canthotomy can be added for improved lateral exposure - Transcaruncular to access the medial wall
Incision: First protect the cornea (corneal eye shield), perform lateral canthotomy if needed, using scissors cut the lateral palpebral fissure horizontal in lateral direction (7 - 10mm). Then rotate inferiorly to lateral canthal tendon (inferior cantholysis).
For transconjunctival incision place between inferior fornix and inferior edge of tarsal plate. *8-10mm from eyelid margin or 5-7mm from tarsal plate *, incise thru periorbita just posterior to orbital rim. Use a malleable retractor to protect globe and contain orbital fat. Can carry as far medially as the lacrimal punctum. Extending medially: incise lateral to the caruncle and medial to the semilunar fold. Can use a forceps to lift/grasp the semilunar fold. Dissect posterior to lacrimal crest and the Horner muscle. Incise periorbita just posterior to Horner muscle. Next cut/ cauterize ant/post ethmoid arteries.
Layers: - lateral canthotomy: skin, orbicularis oculi, lateral canthal tendon, orbital septum, conjunctiva. - Transconjunctival: conjunctiva, periorbital fat, periorbita, orbital rim - Transcaruncular : Important structures: lacrimal sac, anterior ethmoid arteries, posterior ethmoid arteries
Complications: Entropion, ectropion

Rhinoplasty / septoplasty:
Incision:
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Important structures:
Complications:
Gilles:
Incision:
Layers:
Important structures:
Complications: alopecia, temporalis pain
Lefort:
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Complications:
BSSO:
Incision:
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Modified Condylotomy:
Incision:
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Important structures:
Complications: